Department of Health

Medicaid Payments to Selected Providers for Services to Recipients with Medicare Part C Coverage

Individuals who qualify for both Medicare and Medicaid are commonly referred to as “dual eligible.” To receive payment, healthcare providers who render services to dual eligible recipients must bill Medicare prior to Medicaid. Medicare Part C is the segment of Medicare that allows private health insurance companies to administer Medicare benefits. Our audit determined whether the Department Health (Department) had established and implemented adequate controls over Medicaid payments to selected providers for recipients who are also covered under Medicare Part C. We reviewed 270 claims from four providers and determined that three of the providers received overpayments from Medicaid totaling about $758,000. We further determined that many of the overpayments could have been prevented if the Department had certain controls in place on its claims processing system. We recommended certain controls be improved relating to the processing of these claims.